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BLADDER INJURY

The bladder may be lacerated during a hysterectomy, pelvic prolapse repair, or other pelvic surgery. A bladder cystotomy can occur during transvaginal, transabdominal, or laparascopic surgery and the principles of repair are the same. Prompt recognition and repair of a bladder laceration typically allows healing without sequelae.

Intraoperative

Transvaginal

1. Carefully dissect the vaginal epithelium away from the tissue around the site of the laceration. The goal of dissecting the vaginal wall free from the tissue around the injury is to expose an area of detrusor large enough to allow for careful inspection of the injury and a multilayered closure. If the laceration is anywhere near the intramural course of the ureters, then indigo carmine should be administered intravenously and cystoscopy performed to observe ureteral efflux. In the case of a large laceration, cystoscopy may prove difficult as too much of the instilled fluid may escape via the laceration. If the bladder cannot be distended prior to repair of the laceration, then cystoscopy should be repeated after completion of the bladder repair.

Transabdominal

1. Dissect any overlying tissue or fat away from the detrusor muscle around the site of the laceration. If there is any concern regarding additional areas of bladder injury, then an anterior vertical cystotomy should be performed to allow for thorough bladder inspection. The same anterior cytostomy can be used to inspect the bladder trigone and observe the ureteral orifices for efflux if there is a concern for ureteral injury. If there is no suspicion for another bladder injury, then the primary laceration can be closed without further inspection.

Next Steps—Transvaginal or Transabdominal

2. Repair of the bladder injury can begin once the laceration is well visualized and the surrounding detrusor muscle is exposed. There are multiple techniques for repair but most include a multilayered approach.

3. Start by closing the bladder mucosa with a running 3-0 absorbable suture such as chromic or Vicryl (do not use permanent suture) (Figure 37-1A). Once that is completed, close the detrusor layer with a running locking 2-0 Vicryl suture (Figure 37-1B). Next, fill the bladder with saline via a Foley catheter to make sure there are no significant areas of leakage at the suture line. If there are, reinforce that area with interrupted 2-0 Vicryl sutures to ensure a watertight seal. If the repair is in close proximity to the ureters, it may be useful to perform cystoscopy and observe for ureteral efflux to ensure that the ureters were not obstructed during the repair—this is more typical during a vaginal approach.

4. For most bladder repairs, it is satisfactory to leave just a transurethral catheter. If there is excessive bleeding within the bladder, one may consider leaving a suprapubic tube as well. No perivesical drain is required if the bladder repair ...